Consulting

A large multidisciplinary pain clinic engaged us to conduct a comprehensive review of its medical billing compliance across outpatient, inpatient, and compensation scheme services.

Scope:

We assessed Medicare billing practices, rejection patterns, clinical documentation, referral processes, informed financial consent, and Workers Compensation/CTP claims. The review also included evaluation of the practice management system and internal workflows.

Approach:

Over a two-day on-site visit, we observed the full patient journey and interviewed doctors, nurses, and admin staff to identify compliance gaps and system needs. Our findings were delivered in a detailed report with actionable recommendations.

Key Findings:

We identified serious compliance risks – particularly in inpatient billing and documentation – exposing practitioners to potential findings of inappropriate practice or even fraud. In one workflow, we found that patients could be admitted and discharged without any doctor-signed documentation.

Outcome:

We provided a clear roadmap to address urgent risks and improve systems, processes, and billing compliance across the clinic.

Our client, a bulk billing general practice serving a complex and vulnerable patient population, sought our help to ensure the long-term sustainability of the clinic. Their goals were to:

1. Understand current billing patterns and identify opportunities for improvement

2. Receive support to implement changes

3. Review billing processes for long-term efficiency

We approached the project in three phases:

1. Data Analysis:

We reviewed a full year of Medicare claims – over 10,000 invoices across four GPs – to establish a clear picture of existing billing practices.

2. Quantitative Survey:

A short survey of the GPs revealed areas of agreement as well as inconsistencies between perceived and actual billing behaviours.

3. Qualitative Interviews:

We conducted in-depth interviews to explore billing confidence, time utilisation, and potential barriers. This helped surface practical solutions for improvement.

Findings:

We found the clinic was performing well overall, with strong billing practices in place. However, there were missed opportunities. Our recommendations focused on targeted billing education, better use of technology, and workflow improvements to support financial sustainability without compromising patient care.

Our client, a leading private provider of fertility services in Australia, approached us for advice on a nuanced Medicare billing issue involving a returning doctor. The clinician in question was an Australian-trained medical graduate who had spent over a decade overseas completing postgraduate training. The question was whether he could begin billing Medicare immediately upon his return – despite not yet holding formal specialist recognition in Australia.

The client also needed clarity on a related issue: if the doctor was not eligible to bill in his own name, could Medicare services he provided instead be billed by a supervising clinician?

This was a legally and administratively complex matter that required a detailed review of Medicare law, specialist recognition requirements, and supervision rules. We conducted a thorough analysis of relevant legislative instruments and MBS rules, particularly those governing registrar training and billing under supervision.

We delivered clear, practical advice tailored to the client’s specific clinical setting, outlining:

• When and how the doctor could lawfully begin billing under Medicare
• The conditions under which services could be billed by a supervising specialist
• Relevant MBS items that may be claimed during the transitional period
• Risks and safeguards to ensure ongoing compliance

Our guidance helped the client navigate this challenging scenario with confidence and certainty.

An internationally renowned health service provider engaged us to assess the viability of establishing a network of nurse-led urgent care clinics, potentially supported by GPs and Fellows of the Australasian College for Emergency Medicine (FACEM). The vision was to deliver high-quality care for minor injuries and illnesses – particularly after hours and on weekends – without patients incurring out-of-pocket costs.

Our brief was to analyse all viable funding pathways, including Medicare, private health insurance, and government grants, to support the proposed model. We conducted a comprehensive review and delivered a detailed report outlining:

• All relevant Medicare rebates and how they could apply in a nurse- and GP-supported urgent care setting
• Opportunities to leverage a private short-stay hospital licence to access private insurance funding
• Blended funding models combining public and private sources
• After-hours billing options aligned with the Commonwealth Government’s then-forthcoming Urgent Care Clinics policy

We also presented a range of alternative models – both well-established and innovative – that could further reduce cost burdens for consumers while maintaining clinical safety and financial sustainability.

A primary care provider delivering services through group appointments approached us for a full compliance review of their Medicare billing. While Medicare generally does not support billing for group consultations, this provider’s model was highly specialised and unlike anything we had seen before.

We undertook a detailed legal and billing analysis, reviewing the relevant legislation, Medicare rules, and supporting materials. Our conclusion: with some targeted adjustments, the model could be brought into alignment with Medicare requirements. As long as specific legal and documentation criteria were strictly followed, billing for the group appointments could proceed lawfully.

A medical specialist engaged us after discovering that fraudulent claims had been submitted in her name – over 1,100 services across a nine-month period. Despite acting quickly and in good faith, she received no support from her medical defence organisation or any other body.

Our first priority was to provide peace of mind by helping her make the appropriate notifications to relevant authorities. We then set to work, applying internationally recognised methodologies to analyse the claims. This involved identifying red flags in the billing data, then conducting a deep dive into the corresponding medical records. Fortunately, the doctor had a clear sense of where things had gone wrong and was able to guide our investigation. She was right – just about every trick in the book had been used.

We supported her throughout the entire process, including notification and repayment to Medicare, private health insurers, and affected patients. The total amount repaid was nearly $90,000.